2012
who are seeking pure in-hospital cover. SPECTRA Aqua features an overall annual limit that is based on the number of beneficiaries, and appeals to the healthy member who does not require any out-of-hospital provision.
SPECTRA AQUA CONTRIBUTIONS – 2012
|
BENEFICIARY TYPE |
INCOME CATEGORY(monthly) |
|
Principal Member |
767 |
|
Adult Dependant |
692 |
|
Child Dependant |
271 |
(all children will be charged for)
All benefits are annualised unless otherwise stated
HOSPITAL BENEFIT
|
BENEFIT DESCRIPTION |
BENEFIT |
NOTES |
|
Overall Annual Limit (OAL) |
M+0 = R500,000 M+1 = R700,000 M+2 = R850,000 M+3 = R1,050,000 M+4+ = R1,300,000 |
All benefits and sub-limits are subject to the Overall Annual Limit |
|
Dental (Surgery and General Anaesthesia) |
No Benefit |
|
|
General hospitalisation |
100% of SPECTRA Tariff Subject to OAL at DSP only |
Pre-authorisation required at least 48 hours prior to admission (non-emergency only). In case of emergency, authorisation required within 48 hours after admission. 20% Penalty (min. R3,000) if not pre-authorised Certain procedures are subject to the following co-payments: Endoscopic: Gastroscopy, Colonoscopy and Sigmoidoscopy R1,500 Hysterectomy R3,000 Laparoscopy, Hysteroscopy, Endometrial Ablation R2,500 Non-surgical medical admissions R1,000 (refer schedule of hospital co-payments)
Where services for a PMB in hospital are voluntarily obtained from a non-DSP, a co-payment or levy of 30% will apply |
|
Internal prostheses |
Subject to PMB at DSP only |
|
|
Maternity |
100% of Cost at DSP only Subject to OAL |
Pre-authorisation required Home births subject to R5,000 per confinement Must be registered on Maternity Programme Antenatal classes subject to R500 per family If not authorised, a R10,000 limit will apply to Caesarean Sections |
|
Organ transplants, anti-rejection medication |
Subject to PMB at DSP only |
Pre-authorisation required |
|
Pathology |
100% of SPECTRA Tariff M+0 = R600 M+1 = R850 M+2 = R1,000 M+3 = R1,300 M+4+ = R1,500 Subject to OAL |
|
|
Physiotherapy |
100% of SPECTRA Tariff Sub-limit = R2,000 per family Subject to OAL |
Pre-authorisation required |
|
Psychiatric treatment, substance & alcohol abuse & associated conditions |
100% of SPECTRA Tariff Subject to PMB only = 21 days hospitalisation Subject to DSP only |
Pre-authorisation required |
|
Radiology |
100% of SPECTRA Tariff M+0 = R600 M+1 = R850 M+2 = R1,000 M+3 = R1,300 M+4+ = R1,500 Subject to OAL |
Excludes: Specialised Radiology (refer Specialised Radiology benefit) |
|
Take-home medicine |
100% of SPECTRA Tariff 3 days post-hospitalisation Subject to OAL |
|
|
PMB |
||
| Prescribed Minimum Benefits | 100% of Cost |
Limited to statutory algorithms and protocols for treatment received from a Designated Service Provider (DSP) |
|
HIV BENEFIT |
||
|
HIV/AIDS & related illnesses |
100% of Cost at DSP only Unlimited |
Must be enrolled on Scheme HIV/AIDS DSP and Management Programme Includes: HIV+ members, PEP (Post Exposure Prophylaxis) and MTC (Mother To Child transmission) Where any treatment is voluntarily obtained from a non-DSP, a 30% co-payment will apply. |
|
In-hospital
Out-of-Hospital
Prescribed medication
Pathology
Other out-of-hospital expenses
Non-HIV+ members
Pathology (VCT) |
100% of Cost at DSP Unlimited
100% of Cost at DSP Unlimited
100% of Cost at DSP Protocols apply
100% of Cost at DSP Protocols apply
2 per beneficiary per annum Diagnostic tests only |
Must be enrolled on Scheme HIV/AIDS DSP and Programme Pre-authorisation required Where any treatment is voluntarily obtained from a non-DSP, a 30% co-payment will apply.
Baseline monitoring tests as per protocols only
More than 2 tests per annum: subject to motivation and DSP Adults: HIV-Elisa Children < 18 months: HIV-DNA-PCR and p24-antigen |
| ADDITIONAL BENEFITS | ||
|
Ambulance services |
100% of SPECTRA Tariff Subject to OAL |
No benefit unless obtained from Scheme-preferred provider and certified as essential by Medical Practitioner |
|
Blood transfusions |
100% of SPECTRA Tariff Subject to OAL at DSP only |
Pre-authorisation required |
|
Dialysis |
100% of SPECTRA Tariff Sub-limit = R1,800 per treatment Subject to OAL at DSP only |
Pre-authorisation required |
|
Investigative & surgical procedures in consulting rooms |
No benefit |
|
|
Oncology treatment Chemotherapy, Radiotherapy Biological entities |
100% of Cost for PMBs at DSP only
No benefit. Subject to PMBs |
Pre-authorisation required. 30% co-payment for use of non-DSP Medication available from DSP only |
|
Specialised Radiology (MRI / CT / PET / Bone Density & Radio-isotope scans) |
No benefit. Subject to PMBs |
CHRONIC BENEFIT
| CDL medication (Chronic Disease List) | 100% of Cost Unlimited | Limited to diseases specified in statutory Chronic Diseas List (refer CDL schedule) Member must be registered for CDL (reviewed annually) Subject to SPECTRA Vital Formulary only Medication available from DSP only or 30% co-payment applicable |
| Biological entities | No benefit |
MY SAVER™
(see contribution table below for annualised My Saver™ allowance)
|
Acute Medication |
No benefit. Subject to PMBs |
|
Allied Health Services |
No benefit. Subject to PMBs |
|
Conservative Dentistry |
No benefit. Subject to PMBs |
|
Extended Chronic Medication (CDL+) |
No benefit. Subject to PMBs |
|
External prostheses & appliances |
No benefit. Subject to PMBs |
|
General Practitioner Consultations and associated costs |
No benefit. Subject to PMBs |
|
Medical Specialists |
No benefit. Subject to PMBs |
|
Optical |
No benefit. Subject to PMBs |
|
Nursing services & Hospice |
No benefit. Subject to PMBs |
|
Pathology |
No benefit. Subject to PMBs |
|
Pharmacy-Advised Therapy (PAT) |
No benefit. Subject to PMBs |
|
Physiotherapy |
No benefit. Subject to PMBs |
|
Psychiatric treatment, substance & alcohol abuse & associated conditions |
No benefit. Subject to PMBs |
|
Radiology |
No benefit. Subject to PMBs |
|
Screening benefit |
No benefit. Subject to PMBs |
|
Specialised Dentistry |
No benefit. Subject to PMBs |
Out-of-hospital benefits subject to PMBs at DSP only
SPECTRA Tariff:
1. The Reference Price List for healthcare services as adopted by the Board of Trustees from time to time;
2. Tariff as negotiated by SPECTRAMED; or
3. Single Exit Price for medicines plus the relevant dispensing fees according to a Scheme Formulary; or
4. Tariff as paid by SPECTRAMED for investigative and surgical procedures rendered in a provider’s consulting rooms; or
5. Tariff charged by a SPECTRAMED DSP or preferred provider.
Cost:
In relation to a benefit, the cost of providing for Prescribed Minimum Benefits that must be paid by the Scheme.
Exclusions applicable to SPECTRA Aqua:
In addition to the SPECTRA exclusions and limitations (Annexure D) that apply to all our options, SPECTRA Aqua has the following exclusions, except as set out in the Prescribed Minimum Benefits:
1. In-hospital benefits: Dentistry;
Skin disorders; Diagnostic work-up;
Conservative back and neck treatment; Back and neck surgery;
Functional nasal disorders; Elective Caesarean section; Surgery for Oesophageal reflux; Hip and knee replacements; Cochlear implants;
Auditory brain implants; Internal nerve stimulators.
2. Brachytherapy for prostate cancer
3. Cost of treatment for complications, or direct / indirect expenses related to these conditions as excluded.
Pre-authorisation
Benefits in respect of the following categories are only available once pre-authorisation / registration has been obtained.
| CATEGORY | PROVIDER | PRE-AUTHORISATION | CONTACT NUMBER | CONTACT EMAIL |
| Emergency Transport & Ambulance | EUROP ASSISTANCE | Yes | 0800 773 2872 | Not applicable |
| Chronic benefit registration | MEDISCOR Chroniline™ | Yes | 0861 000 319 | spectramed@mediscor. |
| CDL medication delivery (all options) | OPTIPHARM | Yes | 0860 906 090 | chronic@spectramed.co.za |
| Dental authorisations (Specialised dentistry only) | SPECTRAMED | Yes | 0861 497 497 | dental@spectramed.co.za |
| Hospitalisation (including dentistry) | MSO | Yes | 0860 102 474 | preauth@mso.co.za |
| HIV/AIDS programme (registration/enquiries) | OPTIPHARM | Yes | 0860 906 090 | spectramed@optipharm.co.za |
| Oncology (Chemotherapy/ Radiotherapy) | MSO | Yes | 0860 102 474 | preauth@mso.co.za |
| Oncology medication (all options) | MSO | Yes | 0860 102 474 | preauth@mso.co.za |
